"No performance in surgery more interesting and satisfactory": Harvey Cushing and his experience with spinal cord tumors at the Johns Hopkins Hospital

Abstract

Although Harvey Cushing was a neurosurgical pioneer, his work on the spine remains largely unknown. In fact, other than his own publications, Cushing's patients with pathological lesions of the spine who were treated while he was at the Johns Hopkins Hospital, including those with spinal cord tumors, have never been previously described. The authors report on 7 patients with spinal cord tumors that Cushing treated surgically between 1898 and 1911: 2 extradural, 3 intradural extramedullary, and 2 intramedullary tumors. The authors also describe 10 patients in whom Cushing performed an "exploratory laminectomy" expecting to find a tumor, but in whom no oncological pathological entity was found. Cushing's spine surgeries were limited by challenges in making the correct diagnosis, lack of surgical precedent, and difficulty in achieving adequate intraoperative hemostasis. Other than briefly mentioning 2 of the 4 adult patients in his landmark monograph on meningiomas, these cases-both those involving tumors and those in which he performed exploratory laminectomies--have never been published before. Moreover, these cases illustrate the evolution that Harvey Cushing underwent as a spine surgeon.

Fig. 1

Case 5. This 17-year-old boy presented with difficulty walking, urinary retention, and a 25-lb weight loss. His sensory examination is shown in these drawings by Cushing, with shaded areas representing decreased sensation from a lateral (A), posterior (B), anterior (C), and medial (D) view; his deficits are most consistent with a lesion in the spinal cord at L-5. Cushing noted landmarks in these drawings, including the fibula (A), the interior malleolus (C), and that the view was posterior (B).

Fig. 2

Case 2. This 40-year-old physician from Richmond, Virginia, presented with right arm radiculopathy and bilateral LE weakness. Cushing made a sketch of the patient's sensory examination, which was most consistent with a lesion extending from C-7 through the upper thoracic levels, and has written “Total (?) anesthesia to Pain … on back same—but incl[ude]s most of forearm. Only a very narrow radial strip Escapes.”

Fig. 3

Left: Case 11. This 68-year-old man presented with low-back pain, right LE radicular pain, and urinary incontinence; his examination was remarkable for right LE weakness and hyporeflexia, loss of rectal tone, and saddle anesthesia, depicted in this sketch by Cushing. Right: Case 14. This 40-year-old woman with a history of episodic LE motor and sensory deficits presented with numbness in the region drawn by Cushing. He noted her sensory deficits began “10 cm above the navel” and extended to her midthigh.

Fig. 4

Case 1. This 31-year-old woman presented with progressive paraplegia. Cushing performed an exploratory laminectomy and durotomy, where he found a “large lobulated tumor of the spinal meninges … [it] is impossible to enucleate the growth.” Cushing thought that the growth was a sarcoma, and sketched his intraoperative view, labeling the spinous process of “1st thoracic, completely free” as well as the spinous processes of T-6 and T-7.

Fig. 5

Case 10. This 20-year-old man presented with episodic LE motor and sensory deficits, as well as bowel and bladder dysfunction. Intraoperatively, the only pathological entity that Cushing found was arachnoid adhesions, and he sketched the intraoperative view of the spinal cord.

Fig. 6

Case 7. This 2.5-year-old girl presented with a congenital sacrococcygeal mass which measured 9 × 9 × 4.5 cm. Cushing's meticulous drawings depict this unusual mass from the posterior (A) and lateral (B) views; he also had the child and her mass photographed, with posterior (C) and supine (D) views.